The present invention relates generally to systems, methods, and devices used for hemofiltration. More specifically, the present invention relates to hemofiltration for reducing inflammatory mediator-related diseases (IMRD), which include systemic inflammatory response syndrome (xe2x80x9cSIRSxe2x80x9d), multiorgan system dysfunction syndrome (xe2x80x9cMODSxe2x80x9d), multiorgan system failure (xe2x80x9cMOSFxe2x80x9d),and compensatory anti-inflammatory response syndrome (CARS).
Patients with life threatening illness are cared for in hospitals in the intensive care unit (xe2x80x9cICUxe2x80x9d). These patients may be seriously injured from automobile accidents, etc., have had major surgery, have suffered a heart attack, or may be under treatment for serious infection, cancer, or other major disease. While medical care for these primary conditions is sophisticated and usually effective, a significant number of patients in the ICU will not die of their primary disease. Rather, a significant number of patients in the ICU die from a secondary complication known commonly as xe2x80x9csepsisxe2x80x9d or xe2x80x9cseptic shockxe2x80x9d. Once again, the proper medical terms for sepsis and septic shock are systemic inflammatory response syndrome (xe2x80x9cSIRSxe2x80x9d), multiorgan system dysfunction syndrome 25 (xe2x80x9cMODSxe2x80x9d), multiorgan system failure (xe2x80x9cMOSFxe2x80x9d),and compensatory anti-inflammatory response syndrome (CARS).
In short, medical illness, trauma, complication of surgery, and, for that matter, any human disease state, if sufficiently injurious to the patient, may elicit SIRS/MODS/MOSF or CARS. The systemic inflammatory response within certain physiologic limits is beneficial. As part of the immune system, the systemic inflammatory response promotes the removal of dead tissue, healing of injured tissue, detection and destruction of cancerous cells as they form, and mobilization of host defenses to resist or to combat infection. If the stimulus to the systemic inflammatory response is too potent, such as massive tissue injury or major microbial infection, however, then the systemic inflammatory response may cause symptoms which include fever, increased heart rate, and increased respiratory rate. This symptomatic response constitutes systemic inflammatory response syndrome (xe2x80x9cSIRSxe2x80x9d). If the inflammatory response is excessive, then injury or destruction to vital organ tissue may result in vital organ dysfunction, which is manifested in many ways, including a drop in blood pressure, deterioration in lung function, reduced kidney function, and other vital organ malfunction. This condition is known as multiorgan dysfunction syndrome (xe2x80x9cMODSxe2x80x9d). With very severe or life threatening injury or infection, the inflammatory response is extreme and can cause extensive tissue damage with vital organ damage and failure. These patients will usually die promptly without the use of ventilators to maintain lung ventilation, drugs to maintain blood pressure and strengthen the heart, and, in certain circumstances, artificial support for the liver, kidneys, coagulation, brain and other vital systems. This condition is known as multiorgan system failure syndrome (xe2x80x9cMOSF). These support measures partially compensate for damaged and failed organs, they do not cure the injury or infection or control the extreme inflammatory response which causes vital organ failures.
In recent years, it is increasingly recognized that SIRS/MODS/MOSF exists in phases. In particular, an early pro-inflammatory phase, which is recognized as SIRS, usually occurring within hours or a very few days of significant injury or infection; and a later compensatory anti-inflammatory response syndrome (CARS) which occurs later (5-10 days). SIRS and CARS also appear in repeating and alternate cycles, or concurrently.
A s noted previously, the pro-inflammatory response is critical to host recovery and survival (by healing injury and eliminating infection), but when extreme this response causes vital organ dysfunction or failure. In biology, it is common for one response to be counter balanced by another response; these compensatory responses or systems allow restoration of balance and return the organism (e.g., the patient) to homeostasis. CARS is associated with the abatement of the excess IM characteristic of SIRS, however CARS itself is often extreme and results in immune suppression. SIRS and CARS are each associated with respective characteristic IM. The immune suppression of CARS is very commonly associated with secondary infection. This secondary infection then elicits another SIRS, often worse and more destructive than the first. In patients, it is commonly this second episode of SIRS which is lethal.
Both SIRS and CARS are mediated by excesses of either pro-inflammatory and anti-inflammatory mediators, respectively. Hemofiltration should be as beneficial to CARS as to SIRS. However, in SIRS the improvement should be affirmatively observed by improvement in pulmonary and cardio-circulatory function and survival, whilst in CARS it will be observed negatively, by non-occurrence of secondary infection and secondary SIRS. Both SIRS and CARS may be monitored in a limited way, by monitoring their respective IM in blood, lung or other body fluid.
Hemofiltration with a 100 to 150 kD filter is anticipated to remove the excess circulating IM which respectively characterize SIRS/MODS/MOSF, or CARS. During either condition, it may be desirable to actually supplement IM or provide some other therapeutic agent to augment the system in abatement. In particular, during SIRS/MODS/MOSF when pro-inflammatory IM are in excess, in addition to performance of hemofiltration to remove excess pro-inflammatory IM, the administration of anti-inflammatory IM or therapeutic agents may be useful to additionally abate or otherwise modulate the pro-inflammatory systemic inflammatory response. Similarly, during CARS hemofiltration is expected to remove excess anti-inflammatory IM which should ameliorate immune suppression, in addition, administration of pro-inflammatory IM or other therapeutic agent to promote immune responsiveness, should ameliorate immune suppression of CARS. What is sought is therapeutic synergy between large pore hemofiltration and administration of appropriate therapeutic agents.
In the United States of America each year, SIRS/MODS/MOSF afflicts approximately 400,000-600,000 patients and results in about 150,000 deaths. Overall, depending on the number of organ systems failing, the mortality rate of MOSF ranges generally from 40 to 100%. For instance, if three (3) or more vital organs fail, death results in more the 90% of cases. SIRS/MODS/MOSF and CARS are the most common cause of death in intensive care units and is the thirteenth most common cause of death in the United States of America. SIRS/MODS/MOSF and CARS cost about $5 to $10 billion yearly for supportive care. In addition, the incidence of SIRS/MODS/MOSF and CARS are on the rise; reported cases increased about 139% between 1979 and 1987. This increase is due to an aging population, increased utilization of invasive medical procedures, immuno-suppressive therapies (e.g. cancer chemotherapy) and transplantation procedures. (Morbidity and Mortality Weekly Report 1990; Detailed Diagnoses and Procedures, National Hospital Discharge Survey, 1993, from CDC/National 5 Center for Health Statistics, October/1995.)
The detrimental mechanism of SIRS/MODS/MOSF and CARS is the excessive activation of the inflammatory response. The inflammatory response consists of the interaction of various cell systems (e.g., monocyte/macrophage, neutrophil, and lymphocytes) and various humoral systems e.g., cytokine, coagulation, complement, and kallikrein/kinin). Each component of each system may function as an effector (e.g., killing pathogens, destroying tissue, etc.), a signal (e.g., most cytokines), or both. Humoral elements of the inflammatory response were known as toxic mediators, but are now known collectively as inflammatory mediators (xe2x80x9cIMxe2x80x9d). IM include various cytokines (e.g., tumor necrosis factor (xe2x80x9cTNFxe2x80x9d); the interleukins; interferon, etc.), various prostaglandins, various clotting factors (e.g., platelet activating factor (xe2x80x9cPAFxe2x80x9d), various peptidases, reactive oxygen metabolites, and various poorly understood peptides which cause organ dysfunction (myocardial depressant factor (xe2x80x9cMDFxe2x80x9d). These compounds interact as a network with the characteristics of network preservation and self amplification. Some of these compounds, such as MDF and peptidases, are directly injurious to tissue; other compounds, such as cytokines, coordinate destructive inflammation. Infection (e.g., abscesses and sepsis) is a common complication of critical illness. Certain bacterial exotoxins, endotoxins or enterotoxins are extremely potent stimuli to SIRS/MODS/MOSF and CARS. The development and use of effective antibiotics and other supportive measures have not had a significant effect on the death rate from MOSF. The systemic inflammatory response with its network of systems (e.g., monocyte/macrophage, complement, antibody production, coagulation, kallikrein, neutrophil activation, etc.) is initiated and regulated through the cytokine (xe2x80x9cCKxe2x80x9d) system and IM""s. The CK system consists of more than thirty known molecules each of which activates or suppresses one or more components of the immune system and one or more CK in the network. The CK network is the dominant control system of the immune response. The sources of CK""s are monocyte/macrophages and endothelial cells and they are produced in every tissue in the body. Key characteristics of the CK system are as follows: (i) CK are chemical signals coordinating immune system and associated system activities; (ii) commonly, two or more CK will trigger the same action providing a xe2x80x9cfail safexe2x80x9d response to a wide variety of different stimuli (the systemic inflammatory response is critical to an individual""s survival; these redundant control signals assure a system response which does not falter.); (iii) CK and IM concentrations (usually measured in blood) therefore increase in order to stimulate, control, and maintain the inflammatory response proportionally to the severity of the injury or infection; and (iv) as severity of injury or infection increases, the cytodestructive activity of the system increases resulting in MODS/MOSF. Therefore, high concentrations of CK and IM measured in the patient""s blood, which are sustained over time, correlate with the patients risk of death.
Major research efforts by the biotechnology industry have sought cures for SIRS/MODS/MOSF and CARS, but none to date have been licensed by the United States Food and Drug Administration (xe2x80x9cFDAxe2x80x9d) for use in humans. There is currently no definitive therapy for SIRS/MODS/MOSF or CARS(Dellinger, 1997; Natanson, 1994), even though a great deal of research funds have been spent on failed therapies for sepsis (Knaus, 1997). Critical care medicine techniques available to manage SIRS/MODS/MOSF and CARS are generally supportive in that they do not cure SIRS/MODS/MOSF. The biotechnology industry, however, has developed a number of prospective treatments for SIRS/MODS/MOSF and CARS. The general strategy of these prospective treatments is to identify what is conceived-to be a key or pivotal single CK or IM. This single target CK or IM is then inactivated in an attempt to abate the inflammatory response. The most widely applied technologies used to inactivate CK or IM is binding with monoclonal antibodies (xe2x80x9cMoAbxe2x80x9d) or specific antagonists (xe2x80x9cSAxe2x80x9d). MoAb""s and SA""s are used because they effectively bind the target CK or IM, or its receptor, usually in an xe2x80x9call or nonexe2x80x9d blockade. This strategy is problematic for two (2) reasons. First, the CK system is essential to mobilize the inflammatory response, and through it, the host immune response. If the CK system were blocked, death would ensue from unhealed injury or infection. Second, the CK and IM signals which make up the control network of the immune response consist of many redundant control loops to assure the xe2x80x9cfail safexe2x80x9d initiation and continuation of this critical response. In the field of engineering, control theory indicates that a redundant, self amplifying system will not be effectively controlled by blocking one point, such as one CK or IM (Mohler, 1995).
Also, of interest, note the existing technique of hemofiltration (xe2x80x9cHFxe2x80x9d), which was developed as a technique to control over hydration and acute renal failure in unstable ICU patients. Existing HF techniques may use a hemofilter of some sort, which consists of cellulose derivatives or a synthetic membrane (e.g., polysulfone, polyamide, etc.) fabricated as either a parallel plate or hollow fiber filtering surface. Since the blood path to, through, and from the membrane is low resistance, the patient""s own blood pressure drives blood through the filter circuit. In these HF applications, the hemofilter is part of a blood circuit. In passive flow HF, arterial blood flows through a large bore cannula, into plastic tubing leading to the filter; blood returns from the filter through plastic tubing to a vein. This is known as arteriovenous HF. Alternately, a blood pump is used, so that blood is pumped from either an artery or a vein to the filter and returned to a vein. This is known as arterio-venous HF or pumped veno-venous HF. Ultrafiltrate collects in the filter jacket and is drained through the ultrafiltrate line and discarded. Ultrafiltrate flow rates are usually 250 ml-2000 ml/hour. In order to prevent lethal volume depletion, a physiologic and isotonic replacement fluid is infused into the patient concurrently with HF at a flow rate equal to or less than the ultrafiltrate flow rate. The balance of replacement fluid and ultrafiltrate is determined by the fluid status of the patient.
The pores of most filter membranes allow passage of molecules up to 30,000 Daltons with very few membranes allowing passage of molecules up to 50,000 Daltons. The membranes used to treat renal failure were generally designed to achieve the following specific goals: (i) to permit high conductance of the aqueous phase of blood plasma water needed to permit the formation of ultrafiltrate at a fairly low transmembrane pressure (typically 20-40 mmHg), which requires a relatively large pore size that incidentally passes molecules of up to 30,000 to 50,000 Daltons; and ii) to avoid passage of albumin (e.g., 68,000 Daltons). Note that with these existing hemofilters used to treat renal failure, the ultrafiltrate contains electrolytes and small molecules (e.g., urea, creatinine, and uric acid), but no cells and only peptides and proteins smaller than the membrane pore size. The composition of the ultrafiltrate is very similar to plasma water. Loss of albumin, and subsequently, oncotic pressure, could cause or aggravate tissue edema and organ dysfunction (e.g., pulmonary edema), so hemofilters are designed to avoid this by having molecular weight exclusion limits well below the molecular weight of albumin (e.g., 68,000 Daltons).
During filtration of protein containing solutions, colloids or suspensions, or blood, the accumulation of protein as a gel or polarization layer occurs on the membrane surface. This gel layer typically reduces effective pore size, reducing the filterable molecular weights by roughly 10-40%. Therefore, pore sizes selected are somewhat larger than needed, anticipating a reduction in effective size. Thus, present membranes allow filtration and removal of excess water, electrolytes, small molecules and nitrogenous waste while avoiding any loss of albumin or larger proteins. These membranes are well-suited to their accepted uses, that is, treatment of over hydration and acute renal failure in unstable ICU patients.
Uncontrolled observations in ICU patients indicate that HF, in addition to controlling over hydration and acute renal failure, is associated with improvements in lung function and cardiovascular function. None of these improvements has been associated with a shortened course of ventilator therapy, a shortened ICU stay, or improved survival. The usual amount of ultrafiltrate removed in the treatment of over hydration and acute renal failure is 250 to 2000 ml/hour, 24 hours a day. A few published observations have suggested that higher amounts of ultrafiltrate brought about greater improvements in pulmonary and cardiovascular status; these have resulted in the development of a technique known as high volume HF (xe2x80x9cHVHF). In HVHF, from 2 to 9 liters/hour of ultrafiltrate are taken for periods of from 4 to 24 hours or more. Furthermore, preliminary uncontrolled or poorly controlled studies suggest that HVHF improves survival in patients with SIRS/MODS/MOSF or CARS; there is growing interest in the use of HVHF in SIRS/MODS/MOSF and CARS. There is however great hesitance to use HVHF for the following reasons: (i) the high volumes (currently 24-144 liters/day) of ultrafiltrate require equally high volumes of sterile, pharmaceutical grade replacement fluid; at these high volumes, errors in measuring ultrafiltrate coming out and replacement fluid flowing into the patient could cause injurious or lethal fluid overload or volume depletion; (ii) the high volume of ultrafiltrate removed could filter out of the blood desirable compounds from the patient resulting in dangerous deficiencies; this is currently theoretical, but should be taken seriously; (iii) large volumes of warm (body temperature) ultrafiltrate flowing out of the patient, and large volumes of cool (room temperature) replacement fluid flowing into the patient can cause thermal stress or hypothermia; and (iv) high volumes of replacement fluid add considerable expense to the therapy.
HVHF, as currently practiced, uses conventional hemofilters with pore sizes which provide a molecular weight cutoff of 30,000 Daltons and occasionally of 50,000 Daltons.
The device and process described in U.S. Pat. No. 5,571,418 generally contemplates the use of large pore hemofiltration membranes with pore sizes to provide molecular weight exclusion limits of 100,000 to 150,000 Daltons. With these higher molecular weight cutoffs, these membranes are designed to remove a wider range of different IM""s; these large pore membranes should remove excess amounts of all known IM""s. These large pore hemofiltration membranes have been demonstrated in animal studies to be superior to conventional hemofilter membranes in improving survival time in a swine model of lethal Staphylococcus aureus infection (Lee, P A et al. Critical Care Medicine, April 1998). It is anticipated that they will be superior to conventional membranes in SIRS/MODS/MOSF and CARS. However, it may be anticipated that in HVHF, the large pore membranes may also remove more desirable compounds thus increasing the risk of the negative side effects of HVHF.
Other techniques used in the past to treat acute renal failure and/or SIRS/MODS/MOSF and CARS include hemodialysis and plasmapheresis. Hemodialysis is well suited to fluid and small solute (less than 10,000 Daltons) removal. However hemodialysis membranes remove very few IM (only those smaller than 5000 to 10,000 Daltons) and so have been ineffective in improving a patient""s condition in SIRS/MODS/MOSF and CARS. In the unstable ICU patient, hemodialysis commonly results in rapid deterioration of cardiovascular function and pulmonary function requiring premature termination of the dialysis procedure. Hemodialysis has also been associated with increasing the occurrence of chronic renal failure in survivors of SIRS/MODS/MOSF or CARS. HF was specifically developed (Kramer, 1997) to avoid these complications of hemodialysis and has been very successful in doing so.
Plasmapheresis can be done with both membrane based and centrifugation based techniques. Plasmapheresis separates plasma and all that plasma contains from blood, leaving only formed elements. The removed plasma is usually replaced by either albumin solution or fresh frozen plasma. The removed plasma would contain all IM""s. Studies of plasmapheresis in animal models of SIRS/MODS/MOSF and CARS have shown increased mortality with plasmapheresis compared to untreated control animals. No controlled study of plasmapheresis in humans with SIRS/MODS/MOSF or CARS has ever been done. The expense of albumin and fresh frozen plasma, and the risk of transmission of serious or deadly viral disease with fresh frozen plasma are serious draw backs to the use of plasmapheresis in SIRS/MODS/MOSF or CARS.
Consequently, the prior art remains deficient in the lack of effective methods of treating IM related disease (e.g., SIRS/MODS/MOSF), which is safe. Furthermore, while high volume hemofiltration holds some promises, it is unworkable in its present form and is overly dangerous. Additionally, control theory suggests the concept that inhibiting a single immune mediator(IM) will not succeed in controlling SIRS/MODS/MOSF or CARS. The present invention fulfills this longstanding need and desire in this art.
In accordance with teachings of the present invention a method and system for providing therapeutic agents with hemofiltration for reducing inflammatory mediator related diseases is disclosed. The present invention is particularly beneficial when used in large pore hemofiltration systems.
According to one aspect of the present invention, a hemofiltration system for treating inflammatory mediator related diseases is disclosed. The system includes a hemofilter to receive blood from a specimen and remove selective inflammatory mediators from the blood. The system further includes at least one therapeutic agent used in association with the hemofilter to reduce adverse inflammatory mediator effects.
In a particularized form the system further includes a 100 to 150 kiloDalton hemofilter.
In a further particularized form the system includes an adsorption device associated with the hemofilter.
In another particularized form, the system includes a selective biological agent to reduce adverse inflammatory mediator effects.
In a further particularized form, the system includes a selective pharmaceutical agent to reduce adverse inflammatory mediator effects.
According to another aspect of the present invention, a method for treating inflammatory mediator related diseases is disclosed. The method includes receiving blood from a specimen, filtering the blood using a hemofilter wherein the hemofilter removes selective inflammatory mediators from the blood. The method further includes providing at least one therapeutic agent wherein the therapeutic agent reduces adverse inflammatory mediator effects.
In a particularized form, the therapeutic agent includes a biological agent.
In another particularized form, the therapeutic agent include a pharmaceutical agent.
In a further particularized form, the hemofilter is configured as a 100 to 150 kiloDalton hemofilter.
In another particularized form, an adsorptive device associated with the hemofilter is provided.
One technical advantage of the present invention includes providing rapid stabilization of the septic shock to increase survival rate of a specimen or patient.
Another technical advantage of the present invention includes abating excessive and destructive inflammatory activity which characterizes septic shock.
A further technical advantage includes increasing the effectiveness of therapeutic agents as adjunctive therapy to hemofiltration.